A study of iron and zinc deficiency on short term memory in

children & effect of their supplementation

Jagveer Chaudhary, Rakesh Jora*, Pramod Sharma, Ravinder Gehlot, Sushil
Regional Institute of Maternal and Child Health, Umaid Hospital for Women and Children, Dr. S.N. Medical College, Jodhpur, Rajasthan,
India.

Research Article ABSTRACT :

Article Info
Recived on:04/02/2015
Accepted on: 10/03/2015
Published on:20/03/2015
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Literati
Background-: To identify the role of Iron & Zinc & their combined deficiency on
Short term memory and to assess the response of supplementation therapy in the
deficient children in the age group 6 11 years.
Methods-: In this interventional study 101 children were included from age group
of 6-11 years (subdivided into 6-8 yr and 9-11 yr groups) from two different govern-
ment schools. After collection of demographic data, the study children underwent
hemoglobin, Serum Iron, Serum Total Iron Binding Capacity and Serum Zinc esti-
mation. Verbal, Non-Verbal memory & Concentration assessment was done in all
the children. Iron (2mg/kg/day BD) and zinc (5mg OD) supplemented for a period
of 3 months for children in the deficient group.
Results-: All children with iron and zinc deficiency in both the age groups had
memory & concentration deficits.
Conclusion-: Iron and zinc deficiency is associated with memory deficits in chil-
dren. There is a marked improvement in memory & concentration after supplemen-

O pen Access tation.

Keywords: Iron, Zinc, memory, concentration, Children.

INTRODUCTION:
Micronutrient deficiencies are widespread in many devel-
oping countries and are common among young persons
hailing from low socioeconomic groups. Iron and Zinc
are essential nutrient not only for the normal growth,
health, and survival of children but also for their normal
mental and motor development and cognitive function-
ing. Deficiency is associated with significantly poorer
performance on psychomotor and mental development
scales and behavioral ratings in infants, lower scores on
cognitive function tests and lower educational achieve-
ment tests in preschool and school age children [1].
There are scanty data available regarding behavioral &
cognitive changes occurring due to Fe or Zn or combined
deficiency & no such study done in Western Rajasthan.
So, this study was undertaken with the objective of identi-
fying the role of Iron, Zinc and Combined deficiency( Fe
& Zn) on verbal and nonverbal spheres of memory , and
to find out the difference in affectation of various spheres
of memory in deficient children & assess the response of
supplementation therapy in the deficient children.
MATERIAL & METHODS:
This study was a cross-sectional, community based, inter-
ventional study. It was conducted during the period from
*Corresponding author:
Dr.Rakesh Jora
Regional Institute of Maternal and Child Health,Umaid Hospital for Women and Children, Dr. S.N. Medical College, Jodhpur, Rajasthan, India.
Email-: jorarakesh@gmail.com
Conflict of interest: Authors reported none
December 2011 to December 2012 at the Kendriya Vidy-
alaya No.1, and Goverment Primary school by the De-
partment of Pediatrics, Dr. S. N. Medical college, Jodhpur.
Permission was obtained from the Assistant commission-
er, Regional Office, Jaipur; and Principals of Kendriya
Vidyalaya No.1 & Goverment Primary school . This study
was approved by the college Ethical Committee. Written
informed consent was taken from the parents of children
who participated in the study.
Randomly selected children of both sexes in the age group
of 6 to 11 years were enrolled for the study and subject-
ed to memory assessment and hematological tests. Chil-
dren with infection, fever, history of drug intake for any
illness and girls who had attained menarche were exclud-
ed. Body weight of children without shoes (by bathroom
scale with weighed to the nearest 100g) and height of
children standing erect without shoes on the stadiometer
were taken.
General physical and systemic examination was done to
find out any abnormal finding in any system. They were
grouped into 6-8 years (Group A; n=34) and 9-11 years
(Group B; n=67). Further sub grouping was done based
on levels of Iron and Zinc. hemoglobin estimation is done
doi: 10.15272/ajbps.v5i42.664

Asian Journal of Biomedical and Pharmaceutical Sciences, 2015.

 Rakesh Jora et al: Asian Journal of Biomedical and Pharmacutical Sciences, 5(42), 2015, 12-15.
by Automated hematology analyzer analyzer, Serum Iron
and Serum Total Iron Binding Capacity (TIBC) by colo-
rimetric method, and Serum Zinc by Atomic absorption
spectrophotometry. Based on Serum Iron levels, Total Iron
Binding Capacity (TIBC) and Serum Zinc levels, Group A
(6-8 years; n=34 ) and Group B ( 9-11 years ; n=67 ) cate-
gorized into 4 sub-groups:
Group 1: Iron deficient serum iron <60 meq/dL, TIBC >
360 and serum zinc >65 mcg/ dL) and
Group 2: Zinc deficient (serum iron > 60 mcg/dL, TIBC <
360 and serum zinc <65 mcg/dL).
Group 3: Combined deficient: Those with values sugges-
tive of iron and zinc deficiency,
Group 4: Normal: Children with normal values of Iron &
Zinc.
TESTS FOR MEMORY & CONCENTRATION
The tests were administered to each child in a quiet room.
The environment was comfortable and free of distraction.
Instructions were given to the children according to a
pre-prepared standard protocol. Five tests were selected,
which were generated from different sources [2], including
Wechsler memory scale, Mini mental state examination,
Binet-Kamath scale and Cattels retentivity test, as de-
scribed below.
(1) Digit span: This test is taken from Wechsler Intelligence
scale for Children Revised (WISC-R). This comprises of
span for digit forward and backward. The subject was re-
quired to repeat a series of numbers called by the research-
er and the difficulty level increased after each successful
answer. Each correct answer was given a score, which was
summed for the final score. The maximum number of dig-
its used in the series is limited to 9. This test is a measure
of attention , short term memory and auditory sequencing.
a. Digit forward: The subject is instructed to recite digit se-
quences of increasing length in the order presented.
b. Digit backward: The subject is instructed to recite digit
sequences of increasing length in the reverse order.
(2)Vocabulary test: This subtest includes 10 unfamiliar
words given to the subjects and instructed to recall them.
This test is a measure of verbal memory.
(3) Benton visual retention test: This test is designed to as-
sess visual perception, visual memory and visual-construc-
tive abilities. There are 10 cards. Each card is exposed for
10 seconds and the child is asked to reproduce the design
from memory. This test measures the visual spatial percep-
tion, visual and verbal conceptualization and immediate
memory span.
(4)Cattells retentivity test: It consists of complex and un-
familiar designs of irregular geometric figures which can-
not elicit any verbal associations. On a card 10 geometrical
figures are presented for 30 seconds, after a 2 minute pause
and from the second card the child has to recognize the
geometrical figures which he has already seen in the first
card. This measures the visual recall for irregular geomet-
rical designs and delayed memory span.
(5)Letter cancellation test: This test is a measure of con-
centration .The children are given the test which has many
alphabets typed out in rows and the children are instructed
Page 13 Asian Journal of Biomedical and Pharmaceutical Sciences, 2015.
to score out the As and Es within a period of 2 minutes. If
the child has omitted to score a letter or if he/she has scored
a letter which is not A or E, it is considered as a wrong. If
the child has correctly struck out an A or E it is considered
as right. The final score is obtained by subtracting the total
of wrongs from the totals of rights.
Deficient children were given the Iron/Zinc supplements
depending on the element in which they are deficient: Syp
Iron (ferrous ascorbate) - 2 mg/kg/day, Zinc - 5 mg once-a-
day in the form of syrup given for 3 months. Children who
were deficient in both the minerals were also given both
Fe & Zn for a period of 3 months. The normal children
were advised nutritious food during the study period & no
intervention was done. All memory tests will be repeated
after three months supplementation of required minerals.
Due to drop outs, only 101 students continued in the study.
Statistical Methods:
The Data was analyzed with the help of Microsoft Excel
2007, statistical software STAT PACK version 3.0 .The
statistical analysis was performed by using students t test
and Chi squire test to find out the significance of difference
in mean between two variables. One way ANOVA (Anal-
ysis of Variance: Single Factor) was done to compare the
effects of the nutritional intervention and improvement in
memory score in different spheres after supplementation
between groups. Continuous data of sample were summa-
rized as mean SD and and categorical data of the sample
were presented as proportion or percentage.
RESULTS:
Out of 101 children, 18.7 % children were deficient in Fe
while Zn deficiency was seen in 12.8 % cases . Prevalence
of Combined deficiency was 3.9% . In both Group A &
Group B, Fe deficiency was 20.6% & 11.9% , followed by
zinc deficiency in 11.8% &7.5% and combined deficiency
in 5.9% & 3.0% cases respectively. Zinc deficiency & com-
bined deficiency ( Fe & Zn) were more common in males
while Fe deficiency was having female preponderance (M
:F= 1:1.5). There was non - significant improvement in
anthropometric measurements after supplementation i.e.
weight, height and BMI in all deficiencies group i.e. Fe de-
ficiency, Zn deficiency and combined deficiency as well as
in control.
Verbal and Non- Verbal aspects of memory was affected in
both age groups due to deficiency of Iron and Zinc. Verbal
memory and Concentration showed statistically signifi-
cantly affection in the 6-8 years age group.
Significant affectation of Verbal, Non - Verbal memory and
Concentration was seen in 9-11 years age group [Table 1].
In 6 8 yr age group, Verbal memory is mainly affected in
Fe deficiency which was improved after supplementation
& significant improvement was also seen after combined
supplementation of Fe & Zn in Combined deficient group.
While In 9 11 yr age group, Zinc deficiency mainly affects
the verbal memory which was improved significantly after
zinc supplementation [Table 2]. Non-verbal memory was
mainly affected in 9-11 years of age group by deficiency
of Iron, Zinc and their combined deficiency, the greater in
the combined deficient group & improved significantly af-
 Rakesh Jora et al: Asian Journal of Biomedical and Pharmacutical Sciences, 5(42), 2015, 12-15.

ter supplementation of deficient micronutrient [Table 2]. an important tool for a good academic performance and
Concentration scores were improved significantly in both plays an important role in modifying the childs potential
age groups after supplementation of deficient micronutri- for learning, which influences behavior.
ents [Table2]. Tests of verbal memory assess the immediate verbal mem-
DISCUSSION ory
The age for cultivating inspiration and wisdom is from 6-8 After supplementation of deficient micronutrient for 3
years, and 9-11 years is considered to be important in the months, 6-8 years age group showed marked improvement,
formative process and reasoning. This is the reason for the particularly in the combined deficiency group, suggesting
focus of our study in this particular age group. Memory is a greater tendency to revert to the normal growth. A study
Group A (6-8 Yr) (1)Iron (2)Zinc (3)Combined Defi- (4)Control p- Value
Deficiency Deficiency ciency [ n = 21 ]
[n= 7 ] [ n =4] [ n =2]

Verbal Memory 6.43 3.6 8 2.28 6 0.0 11.05 2.29 <0.001

Non-Verbal Memory 9.14 4.34 8.75 5.19 9.5 + 6.36 14.09 3.60 >0.05
Concentration 28 1.53 28.75 1.26 20.5 0.71 29.38 2.22 <0.001
Group B (9-11yr) (5)Iron (6)Zinc (7)Combined (8)Control
Deficiency Deficiency Deficiency [n=52]
[n=8] [n=5] [ n =2]

Verbal Memory 11.75 2.71 8.8 2.95 7.5 0.71 11.40 1.99 < 0.01
Non-Verbal Memory 15 2.88 15 3.08 10.5 0.71 15.75 1.57 < 0.01
Concentration 28.87 1.88 25 5.66 22 12.73 28.79 2.14 <0.05
Table 1: Memory Scores in Different Groups before Supplementation
*Significance by One way ANOVA test: all values are in Mean SEM

Group A (6-8 Yr) (1)Iron (2)Zinc (3)Combined Defi- (4)Control p- Value

Deficiency Deficiency ciency [ n = 21 ]
[n= 7 ] [ n =4] [ n =2]

Verbal Memory 4.14 1.67 1.25 1.5 40 0.95 1.43 <0.001

Non-Verbal Memory 3.14 1.67 4.25 3.2 2 2.83 1.61 1.98 >0.1
Concentration 2.14 1.06 1.75 0.5 7.5 3.53 0.42 2.61 <0.01

Group B (9-11yr) (5)Iron (6)Zinc (7)Combined (8)Control

Deficiency Deficiency Deficiency [n=52]
[n=8] [n=5] [ n =2]

Verbal Memory 0.25 1.38 3.4 2.5 1 1.41 0.75 2.13 <0.05
Non-Verbal Memory 2.62 2.92 2.8 3.03 4.5 2.12 0.36 1.64 <0.0001
Concentration 2.12 1.88 5.2 5.02 5 7.07 1.23 2.17 <0.001

Table 2: Improvement in Memory Scores after Supplementation

*Significance by One way ANOVA test: all values are in Mean SEM
in Wechsler intelligence scale for Fe deficient children of
6-8 years for items on verbal and performance subtests
were improved with iron supplementation. Bruner et al [5]
observed that after the 8-week supplementation of iron in
girls, who performed better on a test of verbal learning
and memory than girls in the control group. Tamura et al [6]
observed that with zinc deficiency in 5 years old children,
there was no change in Verbal ability scaled score and Au-
ditory Sequential Memory score.
For the assessment of Non verbal memory in our study, we
have used Benton visual retention test and Cattell retentivi-
ty test. These tests evaluate immediate memory and visuo-
spatial abilities using visual designs. Non-verbal memory
was mainly affected in 9-11 years of age group by deficiency
of Iron, Zinc and their combined deficiency. After supple-
mentation of deficient micronutrient for 3 month, 9 11 yr
age group showed statistically significant improvement in
Non Verbal memory in all deficient group.
Chellappa et al [7] studied the effect of Iron and Zinc supple-
mentation on cognitive functions of female adolescents in
Chennai and observed that groups supplemented with Fe
and combined i.e. Fe & Zn scored higher on the cognitive
function of visual memory than the Zn and control groups.
Based on their findings it appears that the cognitive func-
tion of visual memory is influenced more by iron status
than zinc status. While, we have found the significant im-
provement in non- verbal memory score in all 3 deficient
group supplemented with Iron, Zinc and Combined (Fe &

Asian Journal of Biomedical and Pharmaceutical Sciences, 2015.

Page 14
 Rakesh Jora et al: Asian Journal of Biomedical and Pharmacutical Sciences, 5(42), 2015, 12-15.

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Cite this article as :
Soemantri et al [9] showed that Changes in the iron status of Jagveer Chaudhary, Rakesh Jora, Pramod Sharma, Ravinder Ge-
iron-deficient anemic children were associated with signif- hlot, Sushil. A study of iron and zinc deficiency on short term
icant changes in their performance on the school achieve- memory in children & effect of their supplementation. Asian Jour-
ment and concentration tests. Agarwal et al [10] concluded nal of Biomedical and Pharmacutical Sciences, 5(42), 2015, 12-15.
that the anaemia is associated with lower levels of attention
and concentration in 6 8 yr aged children similar to our
study.
The lack of significant improvement in cognition / memory
in this study could be attributed to the possibility of other
coexisting micronutrient deficiencies such folate, ribofla-
vin, vitamin C and vitamin B-12 in the population studied.
This inference is supported by the findings of Goodwin et al
[11]
who found significant correlation between biochemical
indices of vitamin status and cognitive functioning. They
reported significant correlation between folate, riboflavin,
vitamin C and vitamin B-12 status and memory capacity.
We conclude that Iron and zinc deficiency is associated
with memory deficits in children. There is a marked im-
provement in memory & concentration after supplemen-
tation. Identification of the common micronutrient defi-
ciency at an early age and proper supplementation would
prevent derangement in cognitive function in the later age.
Additional studies should be conducted to examine the
recommendation of giving iron and zinc together for bet-
ter expression of cognitive potential in school age children.
Page 15 Asian Journal of Biomedical and Pharmaceutical Sciences, 2015.